Contractor EMR Certification Form.pdf
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- Solicitation number
- 36c24920r0065
About this file
This document contains a pre-award contractor safety and environmental record evaluation form for Solicitation 36C24920R0065 to renovate B-Ground for acute care at a Veterans Affairs medical center. The form requests contact information and safety data including number of man hours, OSHA recordable injuries, days away from work rates, and serious violations over the past three years. It also asks for the company's NAICS code, safety program administrator, and experience modification rate as well as copies of the past three years of OSHA 300 forms.
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Pre-Award Contractor Safety and Environmental Record Evaluation Form
Information provided below is current and applicable to Solicitation 36C24920R0065
Company Name: ______________________________________________ Address: _____________________________________________________ Telephone: ______________________ Fax: ________________________ Email: _______________________________________________________ Contact: ______________________________________________________
1. Utilizing your OSHA 300 Forms, please complete the following information:
Category 2017 2018 2019
Number of man hours (jobsite and office).
Number of cases involving days away from work, restricted activity, or both (Column H and I of OSHA 300).
Days away, restricted, or transferred rate (# of days away, restricted, or transferred cases x 200,000/# of man hours) (DART Rate).
Number of serious, willful, or repeat violations from OSHA within the last 3 years. Please attach explanation for any violations.
Please attach copies of the following documents: OSHA 300 and 300a Forms. These forms can be accessed through the OSHA publications search page:
http://www.osha.gov/pls/publications/publication.html.
2. Provide six-digit North American Industrial Classification System (NAICS) Code for this acquisition: __________________________________
3. Who administers your company’s Safety and Health Program?
4. Company’s Insurance Experience Modification Rate
(EMR): ____________________________
http://www.osha.gov/pls/publications/publication.html
File details come from the government source that posted it. Updated .